A Multi-Site Evaluation of Prison-Based Drug Treatment: A Research Partnership Between

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1 A Multi-Site Evaluation of Prison-Based Drug Treatment: A Research Partnership Between The Pennsylvania Department of Corrections and Temple University Final Report to the Pennsylvania Commission on Crime and Delinquency, Subgrant #15286 April 16, 2009 Wayne N. Welsh, Ph.D. Department of Criminal Justice 5 th Floor Gladfelter Hall (025-02) 11 th St. and Berks Mall Temple University Philadelphia, PA Principal Investigator This project was supported by Grant Number 2004-DS awarded by the Pennsylvania Commission on Crime and Delinquency to the Crime and Justice Research Center (CJRC), Temple University. Points of view or opinions in this document are those of the author and do not necessarily represent the official position, policy, or view of the Pennsylvania Commission on Crime and Delinquency. 1

2 Table of Contents Executive Summary 4 Project Description 11 Literature Review 12 Research Questions 21 Project Scope and Methodology 22 Background 22 Research Design 24 Sample 26 Instruments 27 Outcome Measures 31 Analytical Approach 33 Findings and Analyses Inmate Characteristics 35 Program Characteristics 38 Recidivism Findings 45 Reincarceration 48 Rearrest 62 Drug Relapse 73 Conclusions and Recommendations 82 Major Findings 82 Implications and Recommendations for Policy 94 Limitations 98 Conclusion 101 References 102 List of Tables Table 1. Research Partnership Steering Committee ( ) 24 Table 2. Treatment Program and Offender Variables 28 Table 3. Post-Release Outcome Measures and Sources of Data 32 Table 4. Sample Characteristics by Comparison vs. Experimental Group 36 Table 5. TC Program Descriptors 39 Table 6. Inmate Characteristics by TC Program: Oneway ANOVA 42 Table 7. Type of Release From Prison by Comparison Group 46 Table 8. Time at Risk since Release from Prison by Comparison Group 47 Table 9. Stepwise Logistic Regression of Reincarceration Rates 52 Table 10. Survival Analysis: Life Tables for Reincarceration 53 Table 11. REST and CRC Scales x Reincarceration Oneway ANOVA Results 58 Table 12. Principal Component Factor Loadings of REST and CRC Scales 59 Table 13. Stepwise Logistic Regression of Rearrest Rates 66 2

3 Table 14. Survival Analysis: Life Tables for Rearrest 67 Table 15. Stepwise Logistic Regression of Drug Relapse Rates 76 Table 16. Survival Analysis: Life Tables for Drug Relapse 77 Table 17. Effects of TC and other Predictors on Three Measures of Outcome 83 List of Figures Figure 1. Framework for Research Design 29 Figure 2. Estimated Probabilities of Reincarceration for Comparison and TC Groups 54 Figure 3. Estimated Probabilities of Reincarceration by Post-Release Employment Status 55 Figure 4. Reincarceration Survival Function by TC v. Comparison Group 56 Figure 5. Estimated Probabilities of Rearrest for Comparison and TC Groups 68 Figure 6. Estimated Probabilities of Rearrest by Post-Release Employment Status 69 Figure 7. Rearrest Survival Function by TC v. Comparison Group 70 Figure 8. Estimated Probabilities of Relapse for Comparison and TC Groups 78 Figure 9. Estimated Probabilities of Relapse by Post-Release Employment Status 79 Figure 10. Drug Relapse Survival Function by TC v. Comparison Group 80 3

4 Executive Summary The Problem Therapeutic community (TC) drug treatment programs have become the preferred treatment approach in correctional settings. Previous evaluations of prison-based TC have produced promising results, including significant reductions in recidivism over follow-up periods ranging from three to five years. However, studies have also been criticized for small sample sizes, less-than-optimal research designs (e.g., uncontrolled selection and attrition biases), and insufficient attention to interactions between inmate characteristics, treatment process, and treatment outcomes (e.g., rearrest, reincarceration, drug relapse). No studies have examined prison-based TC across multiple sites while controlling for individual and programmatic variations in analyses of outcome. Numerous questions remain about the true impact of prison-based TC, and the potential impacts of unmeasured variations in inmate characteristics, treatment programs, and multiple outcome measures. Purpose of This Project The purpose of this project was to examine multiple, post-release outcomes over a post-release period of five years for inmates who participated in Therapeutic Community (TC) drug treatment programs or comparison groups at five Pennsylvania State Correctional Institutions (SCI's). The research was greatly facilitated by a strong, collaborative research partnership between Temple University and the Department of Corrections which began in 1998 and continues to the present. Research Design Using a combination of automated databases and manual data collection techniques, we collected post-release data (e.g., reincarceration, rearrest, drug relapse, employment) on 2,809 inmates admitted to a drug treatment program at five state correctional institutions (SCI) between January and November of Adhering to principles of informed consent, we previously collected pre-treatment (e.g., demographics, criminal history, and assessed need for drug treatment) and in-treatment data (e.g., psychosocial functioning, inmate responses to treatment) for all research subjects. The current grant allowed us to add 1,079 additional cases (i.e., new releases from prison) to a prior research sample, increasing our total n to 2,693 cases, and extending the post-release follow-up period to five years. We examined in-treatment predictors and multiple post-release outcomes for inmates who participated in TC drug treatment programs (n = 749) or comparison groups (n = 2,060) at five state prisons. Matched comparison groups made up of TC-eligible inmates participating in less intensive forms of treatment (e.g., short-term drug education and outpatient treatment groups) at the same five institutions were constructed based upon known predictors such as drug dependency, need for treatment and criminal history. Process and outcome measures incorporated a range of institutional, intermediate (e.g., attitudinal and behavioral change, participation in treatment) and post-release measures (e.g., drug relapse, rearrest and reincarceration). 4

5 Major Results No prior studies have simultaneously examined or reported all three outcomes used in this study. Three different outcomes (reincarceration, rearrest, and drug relapse) were tracked for the experimental (TC) and control groups for up to five years or more, making these results comparable to the longest follow-up studies on prison TC conducted to date. In addition, this study had a much larger sample than previous studies, and was better able to account for individual and programmatic differences across multiple sites. Three main research questions were examined. 1. How effective are in-prison TC programs in reducing drug relapse and recidivism rates (rearrest and reincarceration), and do in-prison therapeutic community programs improve long term outcomes of released offenders (i.e., length of time without drug relapse, rearrest or reincarceration)? 2. Which kinds of inmates benefit most from in-prison TC programs? 3. How do inmate v. programmatic factors independently and interactively influence long term outcomes? Effectiveness of Prison-Based TC Drug Treatment Major results are shown in the table below. TC had a strong, significant impact on reducing the probability of reincarceration over the five year follow-up period. The effect on rearrest was marginally significant (p <.09); the effect on drug relapse was minimal. Possible explanations for these findings are discussed in the report. Major Results: Effects of TC and Other Predictors on Three Measures of Outcome Outcome Comparison Group TC Group Was TC Effective? Other Significant Predictors (+ or indicates direction of Reincarceration Rate effect on outcome) 59.3% 50.5% Yes (p <.05) Time remaining until minimum release date (-); Successful completion of TC (-), Post-release employment (-), Time at risk in the community (-). Rearrest Rate 59.3% 52.3% Marginally (p <.09) Time remaining until minimum release date (-); Age (-); Current Offense Severity (-); Prior Offense Severity (+); Post-release employment (-); Time at risk in the community (-). Drug Relapse Rate 51.2% 50.8% No (p >.10) Time remaining until minimum release date (-); Post-release employment (-); Need for treatment (+); 5

6 The non-significant effect of TC on drug relapse accords with mixed findings from prior research. Only one of the three major prison TC studies (Delaware) examined drug urinalysis as an outcome and found significant treatment effects. While prison TC addresses both addiction and criminal behavior, it is clear that the two types of behavior can exist independently, and drug using behavior appears more resistant to change. In contrast to previous studies, prison TC alone did result in a significant mean effect size for reincarceration and rearrest. In prior studies, TC reduced drug relapse only when mandatory aftercare was provided. Mandatory aftercare may thus be more important for reducing drug relapse than criminal recidivism. Most inmates who were reincarcerated in this sample were returned to prison for a parole violation rather than a new conviction. Increases in parole violations (especially for technical parole violations such as drug or alcohol use), rather than increases in crime per se, have fueled rapidly increasing rates of incarceration observed over recent years. Our results, therefore, support arguments that changes in crime control policies, rather than crime rates per se, are the major drivers of incarceration rates. The first twelve months following release from prison are a particularly critical period of reentry. A very high short-term failure rate was observed for relapse in particular, suggesting that much greater efforts are needed to improve successful reintegration for drug-involved offenders. Much more comprehensive and coordinated efforts are needed to address both risk and protective factors during the first year back from prison. Inmate characteristics predictive of long term success One of the most consistent empirical findings in criminology is that previous criminality predicts future criminality. However, for two out of three outcomes examined (reincarceration and drug relapse), prior offense severity had no effect at all. Only for rearrest did we find a significant (positive) relationship with prior criminality. Even then, prior offense severity dropped out of the equation after all control variables were entered. Results question arguments that criminal propensity remains stable throughout the life course. Rather, criminal propensity appears to be changeable in response to intensive, well-structured treatment (i.e., prison based TC). Current offense severity actually predicted lower rates of rearrest (even after entering all control variables); this lends further ambiguity to the idea that prior criminal behavior is a stable predictor of future criminal behavior. PADOC s own studies have found consistently lower rates for violent and sex offenders than for property and drug offenders. Part of the explanation is that less serious crimes such as property and drug offenses are committed more frequently, while serious crimes such as rape and murder are rarer. Results supported arguments that dynamic rather than static predictors are better predictors of recidivism, and that criminal propensity, if such a thing exists independently of an individual s social context and experience, may be malleable in response to well-implemented, intensive criminal justice interventions, as well as other turning points. 6

7 Inmates who had more time remaining in their minimum sentence upon admission to prison drug treatment had lower reincarceration, rearrest, and drug relapse rates upon release from prison. It is possible that inmates who were motivated to participate in drug treatment benefited from receiving treatment somewhat earlier in their sentence. A second possibility is that there was a deterioration effect of treatment over time, at least for inmates who remained in prison following successful treatment completion. Inmates who successfully completed treatment had lower reincarceration and rearrest rates than those who did not. However, when personality characteristics (motivation, negative affect, and self confrontation) were entered into regression equations, the effects of treatment retention became nonsignificant. It is likely, therefore, that dynamic individual characteristics such as motivation influence one s likelihood of both entering and completing treatment. Inmates who were at risk in the community for longer periods of time did better on the post-release outcomes of reincarceration and rearrest (although time at risk was examined mainly as a variable to control for the passage of time). This effect remained after controlling for baseline individual characteristics. It appears that inmates who did not recidivate during the first two years of their release from prison had a higher likelihood of desisting from crime. Inmates who were employed full-time or part-time did much better than those who were unemployed and/or unable to work (confirming results of prior studies). In fact, the magnitude of effect of postrelease employment was stronger than that of treatment (i.e., participation in TC). Inmates employed full-time showed the lowest rates of reincarceration and drug relapse. For rearrest, however, only older inmates benefited from fulltime employment. Relationships between employment, recovery, recidivism, and relapse are discussed further in the report. An age effect was found for rearrest only, and was based on official records rather than offender selfreports. Consistent with previous research, younger offenders had higher rates of rearrest. However, older (rather than younger) offenders had slightly higher rates of drug relapse. These results are consistent with the findings of Laub and Sampson (2003), who found that the peak age for drug offending was later and the rate of decline in drug offending over time was slower. Influence of Individual and Programmatic Factors on Long Term Success Psychosocial characteristics of inmates at baseline (e.g., anxiety, depression, hostility) were not strong predictors of post-release outcomes; post-release employment remained the strongest predictor. No significant interactions between TC program and individual inmate characteristics predicted rearrest, reincarceration, or drug relapse. These results hint that post-release contextual variables (e.g., human and social capital) rather than individual factors are more predictive of successful reentry. However, individual inmate traits may also change over time in response to treatment, as well as in response to post-release factors such as social supports, opportunities, peer associations, etc. 7

8 Treatment effects were invariant across the five institutions, although variance in outcomes was greatest for drug relapse. All five programs previously evidenced implementation fidelity, and all five programs were of similar duration. Programs did vary somewhat on dropout rate and other contextual factors, however (see Methods section). There is little doubt that assessing programmatic and institutional variation in independent (e.g., treatment) and dependent (e.g., recidivism) measures can be a useful exercise both for theoretical and policy purposes. However, the relatively small number of programs assessed remains a substantial challenge for researchers that seek to examine between-program characteristics. Implications and Recommendations for Policy It is generally agreed that a multistage therapeutic community treatment continuum (TCTC) for drug dependent offenders (e.g., TC treatment in prison, followed by transitional TC in a work-release setting, followed by supervision and aftercare treatment in the community) is associated with significant reductions in drug use and crime for up to 5 years after prison release. This evidence-based intervention has become the dominant paradigm for treating drug dependent inmates. Our results support evidence regarding the efficacy of this approach, but also highlight some pressing needs for further research. Unexamined variations in TCTC implementation practices (e.g., staff selection, training, and evaluation) and implementation outcomes (e.g., fidelity) are likely to influence client outcomes, especially when multiple programs, institutions, agencies, and measures are examined. Despite recommendations that treatment researchers need to more systematically measure implementation processes as predictors of treatment outcomes, researchers have been relatively slow to assess such factors. Between-program, between-unit, and between-agency differences in implementation practices and outcomes may threaten the internal validity of many multisite outcome studies. Policy-relevant research would benefit greatly from more careful attention to mapping critical dimensions of implementation associated with TCTC, and examining how diverse implementation practices (including core implementation components, organizational factors, and external influences) influence outcomes. Several other policy-relevant questions about prison TC remain unanswered. Perhaps most important among these are How long does prison-based TC need to be in order to be effective? Studies are needed to address questions about the stability and generalizability of prison TC effectiveness, given that the definitive studies were all based on treatment durations of 12 months or more, while the majority of prison drug treatment programs (61%) now last 6 months or less. Almost no research has specifically sought to identify the minimum length of treatment needed to realize significant reductions in postrelease criminal behavior and drug abuse. In general, policy-relevant research should further explore more detailed interactions between inmate characteristics, treatment process, and post-release outcomes. There is good reason to believe that prison TC can be a life altering experience for many drug involved offenders, but future research should incorporate a longitudinal perspective that includes more detailed assessments of the diverse individual, programmatic and environmental influences of offender behavior pre-, during-, and post-prison. 8

9 Limitations Missing data on the instruments measuring inmate responsiveness to treatment (REST and CRC) at Time 2 (6 months) and Time 3 (12 months) limited our ability to examine inmate responsiveness to treatment over time, or examine relationships between during-treatment change and recidivism. More research is definitely needed to assess to what degree dynamic risk factors change over time in response to prison-based TC drug treatment, and what kinds of individuals may be most likely to benefit from well-implemented TC treatment. In the current study, major variables predictive of recidivism were statistically controlled, constituting a strong alternative to a randomized experiment (Mitchell et al., 2006; Pearson & Lipton, 1999). It is still possible, however, that unmeasured sources of bias could have influenced the results. Wellcrafted experimental and longitudinal studies are still needed to examine inmate responsiveness to treatment and long term outcomes. While we cannot rule out the possibility that some inmates may have received some kind of postrelease aftercare treatment, the lack of mandatory aftercare treatment for released offenders in PA and the scarcity (and expense) of residential beds available for ex-offenders seriously restrict the likelihood that such services were provided on any meaningful scale to inmates in our sample. It is possible that previous studies may have overstated the effects of community aftercare, and understated the independent effects of prison TC treatment on long term outcomes. However, glaring differences in definitions and implementation of aftercare services across jurisdictions have inhibited advances in this area of research. Although the measurement of employment preceded the measurement of recidivism in the present study, more detailed, longitudinal data on pre- and post-release employment (e.g., type of employment, employee performance, earnings) are needed to examine how non-relapsing or nonrecidivating parolees differ from others. However, none of the control variables examined in this study substantially weakened the observed relationships between post-release employment and three different measures of recidivism, suggesting that the effect of post-release employment is robust. It is possible that larger samples of programs may yield different findings. Two of the five TC units studied were quite large (100+ inmates), and staffing ratios (inmates per counselor) ranged from 9:1 to 26:1. Although overall program dropout rates were low, two programs evidenced lower rates than the others. More systematic assessments of programs as well as individuals are needed, as are larger samples of programs. Conclusions Participation in intensive prison-based TC drug treatment produced significant, long term reductions in recidivism. However, in contrast to previous studies, prison TC exerted strong, significant treatment effects independently of community aftercare, and did so across five different prison sites. The effects of prison TC drug treatment varied depending upon the outcome examined. TC significantly lowered the likelihood of reincarceration and rearrest, but not drug relapse. Post release employment emerged as the strongest predictor of all three outcomes. 9

10 Further research should explore how both individual and programmatic variations influence treatment outcomes over time, and explore why prison-based drug treatment seems to have stronger effects on reducing criminal behavior than drug using behavior. The effects of prison TC and aftercare (both independent v. cumulative and short-term v. long-term) remain ripe areas for future research. 10

11 Project Description The purpose of the proposed project was to examine multiple post-release outcomes for 2,809 inmates who participated in TC drug treatment programs (n = 749) or comparison groups (n = 2,069) at five Pennsylvania State Correctional Institutions (SCI's). Using a quasi-experimental matching design, matched comparison groups made up of TC-eligible inmates participating in less intensive forms of treatment (e.g., short-term drug education and outpatient treatment groups) at the same five institutions were constructed based upon known predictors such as drug dependency, need for treatment and criminal history (NIDA, 1981, 1999). At the expiration of our PCCD grant (Subgrant #1999/2000-DS ) in 2002, 462 TC inmates and 1152 Comparison inmates had been released from prison, with post-release follow-up periods extending up to a maximum of 26 months (mean = 13 months). Numerous significant findings were reported (Welsh, 2002). For example, TC treatment significantly reduced reincarceration and rearrest rates, but not drug relapse rates. The positive effects of TC treatment were contingent upon employment following release from prison. Comparison inmates who failed to obtain full-time employment following release were 9.6 times more likely to be reincarcerated. TC inmates evidenced numerous improvements in psychosocial functioning and active involvement during treatment, including significant decreases in depression and risk-taking behavior, and significant increases in therapeutic engagement, personal progress, trust in group, opinions of program staff, and perceptions of counselor rapport. The major limitation in the initial post-release sample was the brevity of the follow-up period and the attendant small sample sizes available for some multivariate analyses (Welsh, 2002). For example, our ability to examine the predictive power of in-treatment changes (REST and CRC subscales) upon post-release outcomes (recidivism) was limited. At that time, fewer than 100 TC inmates who had 11

12 completed two or more repeated measures on the REST and CRC had been released from prison. Under the additional data collection afforded by the current study, 2,693 of the 2,809 inmates in the original sample (95%) have now been released from prison. With larger sample sizes and follow-up periods extended up to five years, this unique database provides one of the most comprehensive sources of information on prison-based drug treatment ever assembled, allowing researchers to examine critical interactions between client selection, program structure and process, inmate responses to treatment and outcomes. Literature Review Dependent substance abusers are responsible for a high proportion of crime (Ball et al., 1983; Chaiken, 1989; Inciardi, 1979; Lipton, 1995). For chronic users, activities and behaviors surrounding drug acquisition and use pervade their lifestyle (Johnson et al., 1985; Walters, 1992). Drug-involved offenders comprise a large portion of local, state and federal correctional populations. At midyear 2005, 2.2 million inmates were incarcerated in U.S. jails and prisons, a rate of 738 per 100,000 adults (up from 601 in 1995) (Harrison & Beck, 2006). Drug offenses accounted for 21% of sentenced prisoners under State jurisdiction in 2002, and 55% of sentenced prisoners under Federal jurisdiction in 2003 (Harrison & Beck, 2005). The existing delivery of correctional drug treatment is inadequate relative to need. In the 1997 Survey of Inmates in State and Federal Correctional Facilities, about 2 out of 3 inmates admitted drug histories, but less than 15% received any professional treatment while in prison (Mumola, 1999). Belenko and Peugh (2005) estimated that about one-third of male inmates and more than half of female inmates in this sample needed long-term residential treatment. Although inmates in the most severe drug use categories were more likely to receive treatment while incarcerated, only about one-fifth received any clinical treatment services. 12

13 In the 2004 Survey of Inmates in State and Federal Correctional Facilities, the Bureau of Justice Statistics included for the first time measures of drug dependence and abuse based on criteria specified in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) (Mumola & Karberg, 2006). Fifty-three percent of State and 45% of Federal prisoners met DSM-IV criteria for drug dependence or abuse. Among drug dependent prisoners, 40% of State and 49% of Federal inmates took part in some type of drug abuse program including self-help groups, peer counseling, and drug education. However, the percentage who took part in treatment programs with a trained professional (15%) remained unchanged from In short, a tremendous need for evidencebased prison-based drug treatment remains largely unmet. Prison-based therapeutic community (TC) drug treatment has been shown to be effective in breaking the cycle of relapse and recidivism among seriously drug-involved offenders (Gaes, Flanagan, Motiuk, & Stewart, 1999; Mitchell, MacKenzie & Wilson, 2006; Mitchell, Wilson, & MacKenzie, 2007; Pearson & Lipton, 1999). At the same time, studies of prison TC have been vulnerable to criticisms of inadequate research design, unknown or compromised program implementation, and inadequate measures of treatment process and outcome (Austin, 1998; Fletcher & Tims, 1992; Gaes et al., 1999; Mitchell et al., 2006). Critical questions regarding interactions between inmate characteristics, treatment process, and outcomes remain largely unexamined. In-prison TC is a drug-free residential setting which provides an intensive (6-12 months), highly structured pro-social environment for the treatment of substance abuse and addiction. It differs from other treatment approaches principally in its use of the community as the key agent of change, in which treatment staff and recovering clientele interact in both structured and unstructured ways to influence attitudes, perceptions, and behaviors associated with drug use (DeLeon, 2000). In contrast to other types of treatment, TC provides total immersion into the treatment experience, i.e. one is living it full time. 13

14 The TC uses a staged, hierarchical model in which treatment stages are related to increased levels of individual and social responsibility. Peer influence, mediated through a variety of group processes, is used to help residents learn and assimilate social norms and develop more effective social skills. The therapeutic approach generally focuses on changing negative patterns of thinking and behavior through individual and group therapy, group sessions with peers, and participation in a therapeutic milieu with hierarchical roles, privileges, and responsibilities. Strict and explicit behavioral norms are emphasized and reinforced with specific contingencies (rewards and punishments) directed toward developing selfcontrol and responsibility. Inmates typically move through three phases of treatment in a 12-month TC program. The first phase consists of orientation, diagnosis, and an assimilation process. In the second phase, typically lasting 5 to 6 months, inmates are expected to take on increased responsibility and involvement in the program. Those who have been in the program longer are expected to share their insights, teach new members and assist in the day-to-day operation of the TC. Group counseling focuses on self-discipline, self-worth, selfawareness, respect for authority, and acceptance of guidance for problem areas. Seminars take on a more intellectual approach. Debate is encouraged as a means of self-expression. During the third phase, preparation for community reentry, which lasts 1 to 3 months, inmates strengthen planning and decision making skills and design their individual aftercare plans. Many programs add a fourth phase that includes relapse prevention training. 14

15 Effectiveness of Prison TC Techniques of meta-analysis have become popular to analyze treatment effects in different domains. Meta-analyses use quantitative procedures to synthesize the findings from numerous studies. They typically estimate effect sizes due to treatment and examine the influence of factors that may increase or decrease effect size (including characteristics of the sample, the research design, and the intervention). Meta-analysts examining prison-based drug treatment to date have consistently bemoaned the lack of conclusive findings in this area due to methodological weaknesses. In a systematic review prepared for the Campbell Collaboration, Mitchell et al. (2006, 2007) argued that the effectiveness of prison-based TC drug treatment is less clear than commonly assumed, largely due to methodological deficiencies including inadequate comparison groups, inadequate statistical controls, and selection bias. The effectiveness of other types of prison-based drug treatment (e.g., outpatient treatment, 12-step groups) remains largely unknown. Mitchell et al. (2006, 2007) examined published and unpublished studies of prison drug treatment in North America or Western Europe since In addition, the study had to be based upon either an experimental design or two-group quasi-experimental design, the study had to report an outcome measure related to criminal behavior, and the study had to be reported in the English language. Recidivism and drug-use outcomes from each study were calculated using the odds-ratio effect size. Researchers located twenty-six studies meeting the eligibility criteria, and coded 32 different effect sizes (several studies assessed more than one drug treatment program). To avoid confounding due to differential attrition, authors either eliminated studies that used dropouts as a comparison group or (where possible) combined dropouts into the total sample of treatment admissions. Seventeen effect sizes were calculated from TC programs; ten were computed from counseling or drug education programs 15

16 (including 12-step programs); 1 three were from boot camp programs; and two pertained to a jail-based methadone maintenance program. Researchers used a four-point index of internal validity based upon the University of Maryland s Scientific Methods Scale (Sherman et al., 1998). Experimental designs were rated as a 4 unless they had significant attrition, in which case they were rated as a 3. Rigorous quasi-experiments (studies with carefully matched comparison groups and/or multivariate statistical controls for relevant pre-intervention differences) were rated as a 3. Quasi-experiments with questionable comparison groups or lacking multivariate statistical analyses were rated as a 2. Studies where the comparison group was markedly different than the treatment group on pre-intervention characteristics were rated as a 1. Only three studies (9%) were rated 4 on the scientific methods scale, and only eight studies (25%) were rated 3. Twenty-one studies (66%) used methods generally considered too weak to draw valid conclusions (i.e., no matching, inadequate statistical controls, inadequate comparison groups). 2 More curiously, only eleven studies examined post-intervention drug use as an outcome variable. Three-quarters of the studies had effect sizes favoring the treatment group over the comparison group, with an overall mean odds ratio of 1.25 (roughly translated into recidivism rates of 50% v. 44.5%). Therapeutic community drug treatment programs produced the strongest overall effect (mean odds ratio = 1.47). Effect size was statistically unrelated to sample characteristics (age, gender, race, or offender type) or program characteristics (e.g., length of intervention, prison v. work-release, inclusion of aftercare component). However, researchers cautioned, few studies provided sufficient detail about characteristics of the samples or the programs, limiting the ability of meta-analysts to make valid conclusions about the influence of such factors on effect sizes. 1 Unfortunately, the authors do not treat these as three distinct types of programs. 2 The paper did not report the methodological quality of the TC studies or other treatment types separately from the total sample of studies. 16

17 In one of the largest meta-analyses of correctional treatment to date, the Correctional Drug Abuse Treatment Project (CDATE) identified 1,606 distinct studies conducted between 1968 and 1996 (Pearson & Lipton, 1999). Similar to the University of Maryland Scientific Methods Scale (Sherman et al., 1998), Pearson and Lipton used a four-point quality of methods scale (1 = poor, very low confidence, 2 = fair, low confidence, 3 = good, midlevel of confidence, and 4 = excellent, high level of confidence) in their analyses. The meta-analysis verified that TC was effective in reducing recidivism, finding a significant, weighted mean effect size of.133. However, of the seven TC studies examined, none was rated as excellent; only one was rated as good; three were rated as fair, and three were rated as poor. Higher quality studies tended to show a slightly higher effect size, although the relationship between method quality and effect size did not reach statistical significance. Pearson and Lipton were able to compute an effect size of TC on drug/alcohol relapse for only one of the studies (of fair methodological quality), finding an effect size of.17. Pearson and Lipton cautioned that methodological weaknesses have limited the conclusions that can be drawn from these studies. Gaes et al. (1999) reached similar conclusions in a review of adult correctional treatment. They particularly noted the persistence of bias caused by subject selection and/or attrition. In many studies, inmates were allowed to self-select into treatment, they were selected on criteria unrelated to their assessed level of need for treatment, and/or they dropped out of treatment at high rates. Dropouts have often been incorrectly analyzed as if they were a valid, independent comparison group (Gaes et al., 1999). In each case, outcomes are potentially biased due to selection or attrition processes (see also Austin, 1998; Pearson and Lipton, 1999). Although Gaes et al. (1999) found evidence of positive prison drug treatment effects, especially prison TC, they offered four warnings: 1) few studies provided detailed descriptions of the treatment delivered; 2) few studies monitored the quality or integrity of program implementation; 3) subject 17

18 selection and attrition bias were persistent problems; and 4) few studies used strong inference designs (i.e., studies that not only detected a treatment effect, but were able to detect a reduction in the client s needs or deficits that was statistically related to observed outcomes). Outside of Pennsylvania, the most extensive evaluations of prison-based TC drug treatment to date have been conducted in three states (Delaware, California, and Texas). These studies are briefly reviewed to clarify the major findings and flaws identified by meta-analyses. The three studies all used extended follow-up periods for tracking outcomes (minimum of three years). Each found that graduates of prison TC had lower rates of recidivism than comparison samples, especially when prison TC was combined with structured aftercare following release from prison. In Delaware, prisoners with a history of drug-related problems are referred to the 12-month KEY Therapeutic Community (TC) program, and following prison release, these individuals go to the CREST program, a 6-month TC-based work-release program for transitional aftercare (Inciardi, Martin, Butzin, Hooper, & Harrison, 1997; Nielsen, Scarpitti, & Inciardi, 1996; Lockwood, Inciardi, & Surratt, 1997). Finally, after release from residential aftercare, the clients receive supervised outpatient-based aftercare. Random assignment was used only for one cohort of inmates randomly assigned to work release (CREST) or not. No random assignment was used to assign subjects to the experimental treatment (KEY, the TC program) or control group. Three years following their release to the community, significantly more of the clients who completed the in-prison program and the transitional aftercare program remained arrest-free (55%) than an untreated comparison group (29%) (Martin, Butzin, Saum, & Inciardi, 1999). Those who also received outpatient aftercare following the transitional residential treatment had the best outcomes (69% arrest free after 3 years). Results for relapse to drug use (as measured by both selfreports and urinalysis) were similar, with 17% of those who completed only the in-prison therapeutic community, 27% who had the in-prison treatment and the transitional residential treatment, and 35% who also had outpatient aftercare remaining drug-free during the follow-up period, compared to only 5% of 18

19 the comparison group. Findings reported for 5-year outcomes were similar, with those who went through both KEY and CREST or through CREST alone having significantly lower recidivism rates than the comparison group (Inciardi, Martin, & Butzin, 2004). According to authors, participation in prison TC treatment alone did not significantly improve 5-year outcomes (p. 103), although those analyses were not presented. In the Amity, California prison study (Wexler et al., 1999), researchers used randomization to assign inmates who volunteered for treatment to either TC or a wait-listed, intent-to-treat comparison group. Volunteers were deemed eligible for TC if they had a drug problem (no information on the severity of drug problem or the means of assessment was given), and had at least 9 to 14 months remaining in their sentence prior to parole eligibility. Inmates remained in the TC-eligible pool until they had less than 9 months to serve, then they were removed from the pool and designated as members of the no-treatment control group. In reality, inmates in the no-treatment comparison group may have received some unknown mix of drug education, self-help, or outpatient services: The control group did not receive any formal substance abuse treatment during their prison stay, although limited drug education and 12-step groups were available (p. 325). Those who successfully completed prison TC plus aftercare showed a three-year reincarceration rate of 27%, compared to 75% for a no-treatment comparison group (Wexler et al., 1999). However, when the entire treatment group (i.e., before removing dropouts from TC or aftercare) was considered together, the reincarceration rate for the treatment group increased to 69%, a difference that was no longer statistically significant. Curiously, the five-year outcome results for this sample 3 suggested a rebound effect: the treatment group now had a significantly lower reincarceration rate (76%) than the no-treatment control group (83.4%). It is difficult to interpret the stability of these findings, as the authors acknowledge, because the unbiased assignment 3 Prendergast et al. (2004:43) do not report the sample sizes for the experimental and comparison groups at the five-year followup, although they report that the total sample included 576 subjects. 19

20 of randomization no longer operates, and selection bias becomes a possible (although by no means exclusive) explanation for the findings (Prendergast et al., 2004: 53). In Texas (Knight, Simpson & Hiller, 1999), authors constructed a matched comparison sample (n = 103) based upon TC-eligible inmates who were either rejected by the parole board or who had too little time remaining on their sentence. TC-eligible parolees were rejected because the parole board judged them either as unlikely to benefit from the program or inappropriate for the program (Knight, Simpson, Chatham, and Camacho, 1997:82), introducing selection bias into the research design. Researchers separated treatment admissions into Aftercare Completers (TC + Aftercare; n = 169) and Aftercare Dropouts (TC only; n = 122). Aftercare completers had a 3-year reincarceration rate of only 25%, significantly better than the 42% reincarceration rate of the Comparison group and the 64% reincarceration rate of the Aftercare Dropouts. Because the treatment and comparison groups differed significantly on prior offense and problem severity (and perhaps other unmeasured characteristics), researchers further broke down the three groups into low-risk and high-risk subgroups (six comparisons overall, with sample sizes < 100 in four of the six groups). Treatment effects were greatest for high-risk inmates who completed both TC and Aftercare (3-yr. rearrest rate of 26%). In sum, results from studies of prison-based TC are promising but inconclusive. Studies have been vulnerable to criticisms of inadequate research design, unknown or compromised program implementation, and inadequate measures of treatment process and outcome (Austin, 1998; Fletcher & Tims, 1992; Gaes et al., 1999; Mitchell et al., 2006, 2007; Pearson and Lipton, 1999). The current study attempted to address these gaps in the literature to date. Research Questions Relationships between inmate characteristics, treatment process and outcomes remain only partially understood (Farabee et al., 1999; Fletcher & Tims, 1992; ONDCP, 1996; Pearson & Lipton, 20

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